The Future of Value-based Nursing Care

August 16, 2013 - Value has become one of the latest buzz words in health care, with the advent of value-based purchasing, with its focus on both outcomes and cost, and passage of the Affordable Care Act, which authorized the Hospital Value-Based Purchasing program and expanded accountable care organizations (ACOs) and other value propositions.

“Our U.S. health care system is moving from volume-based--the number of patients you’ve seen--to more value-based, and it’s fundamentally changing the way we are organized and deliver care,” said K. Kelly Hancock, MSN, RN, NE-BC, executive chief nursing officer for Cleveland Clinic in Ohio. “The goal is to provide better care for our patients, better health management for the population, which advanced practice nurses and nurses in the community are involved with, all at a lower cost.”

Outcomes are based on quality of care, health status, processes and the patient experience. Financial incentives differ, and that is shifting the way professionals think about care--from episodic to services across the continuum, at home and in other settings, Hancock added.

The transformation from fee-for-service medicine to value-based care, in which quality metrics are tracked, presents challenges for health care organizations and nursing. But it also creates possibilities for nurses.

“There are opportunities for nurses to lead the way in this,” Hancock said. “Nurses can lead this initiative.”

Cleveland Clinic has established primary, specialty and transitional care coordination positions to provide a structure that allows nurses to help patients and families manage care across the continuum. Those nurses help to ensure patients are following the plan of care and optimally managing their diseases. The care coordinators also promote better communication during care transitions.

Nursing’s economic benefit

Many nursing thought leaders have raised the issue of value-based nursing care and the need to identify and define the economic benefit nurses deliver and their contribution to quality and safety.

“As we move to new payment models, for example bundled payment or accountable care organizations, it will be vital to understand how much nursing care contributes to the results of the care and how we interact together,” said John M. Welton, PhD, RN, dean of the School of Nursing and Health Sciences at Florida Southern College in Lakeland, Fla., and a proponent of value-based nursing care.

“From an economic standpoint,” he added, “we need to determine the metrics of how we are going to achieve higher value, higher quality, better efficiency and better performance of nursing care.”

That will likely require pulling nursing care out of the “room and board charges” hospitals have traditionally charged and establishing a monetary value for it.

“I think it’s hard for nurses to put a dollar value on what we do, because it feels awkward,” Welton said. “But it shouldn’t. Nursing is part of the business of caring.”

Nursing will need to figure out not just their economic value in acute care hospitals but also in rehabilitation centers and home care. As organizations receive bundled payments for the care of populations, it will behoove nurses to be able to articulate their contribution.

“If nurses can demonstrate the economic value and viability of doing a better job, should we not consider giving nurses more money?” Welton added. “The idea is to identify best practices, why they are doing better and emulating that across the system.”

In a white paper written for the Washington State Nurses Association, David M. Keepnews, PhD, JD, RN, NEA-BC, FAAN, director of graduate programs and associate professor at the Hunter-Bellevue School of Nursing at Hunter College, City University of New York, recommended nurses seek information about health financing and policy and how that relates to their jobs, and then advocate for themselves and their patients. Nursing leaders can take that a step further and educate other organizational leaders about nursing’s role in patient and organizational outcomes.

Metrics and nursing care

Quality, a key component of value-based care, is measured by a set of quality indicators.

Data will help move the country to a better performing health care system, Welton added.

Cleveland Clinic shares its quality data, such as skin ulcer rates and patient ratings of the experience, with frontline staff, and nurses have become much more interested in it. Nurses practice at the top of their licensure, and shared governance councils are reshaping models of care and engaging in solutions.

“Our performance is tied to these metrics and payments,” Hancock said. “We have to continue to elevate our expectations of quality and experience at a lower cost. That encourages us to be more innovative on staffing models and delivery of care.”